Visceral leishmaniasis — DTM&H MCQ
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Correct answer: D — Liposomal amphotericin B
The correct answer is D, liposomal amphotericin B. This child has classic visceral leishmaniasis (kala azar): prolonged fever, weight loss, massive splenomegaly and pancytopenia from bone marrow and splenic infiltration, in a patient from an endemic East African region (South Sudan), with a positive rK39 rapid diagnostic test confirming the diagnosis serologically once malaria has been excluded. Liposomal amphotericin B is the treatment of choice because it achieves high intracellular concentrations in the reticuloendothelial system (spleen, liver, bone marrow) where Leishmania amastigotes reside, has excellent cure rates, and has a far better safety profile than conventional amphotericin B deoxycholate or pentavalent antimonials, making it suitable for a child with pancytopenia and likely marrow suppression. UK and international guidance recommends liposomal amphotericin B as first line systemic therapy for visceral leishmaniasis given this efficacy and tolerability profile. Why the other options are wrong: A. Doxycycline alone: this is used for rickettsial disease, brucellosis or as part of malaria chemoprophylaxis, and has no activity against Leishmania amastigotes. C. Praziquantel: this is an anthelminthic active against schistosomes and tapeworms; it does not treat protozoal intracellular infection and would not address this clinical picture. B. Oral chloroquine: this is an antimalarial, and malaria films here are explicitly negative, so an antimalarial agent is not indicated and has no antileishmanial activity. E. Albendazole: this is a benzimidazole anthelminthic used for soil transmitted helminths, hydatid disease or lymphatic filariasis, and has no role in leishmaniasis. Key point: Fever, massive splenomegaly and pancytopenia with a positive rK39 test in a patient from East Africa indicates visceral leishmaniasis, treated with liposomal amphotericin B rather than antimalarial or anthelminthic agents.
Reference: Amphotericin B Gilead liposomal (AmBisome) Summary of Product Characteristics, electronic medicines compendium (emc), medicines.org.uk, visceral leishmaniasis dosing section (total dose 21.0 to 30.0 mg/kg over 10 to 21 days), https://www.medicines.org.uk/emc/product/1022